05762 (PAT)T4ht 4 4 Q"
Building
Address 78-695 Sago
Owner
Address 78.695 ' Sagwwo
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
City Zip _ Tel.
La {uinta 922.53
Contractor
Baer _ Builder
Address
Tela
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
A=
affirm that I am licensed under provisions of Chapter 9 (commencing with Section
effec t of Division 3 of the Business and Professions Code, and my license is in full force and
effec
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec- 7031-5,13usiresa and Professions Code: Any City or county which requires a
pemrit to construct. alter. improve, demofsh, or repair any structure, prior to its issuance also
requiem the applicant for such permit to We a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the &rsiness and Professions Code, or that. he is exempt therefrom, and Ore basis
for the alleged exemption- Any vfofaton of Section 7031.5 by .any applicant for a permit
subjects the app6vnt to a ciO penalty of not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Ouishess and
Professions Code: The Contractors License Law does not appy to an owner of property who
builds of improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the burbling
or improvement is sold within are year of corrpletron, the owner4wi7der will have the burden
of proving that he did not build or improve for the purposeof sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project (sec. 7044, Business and Professions Code: The Contractors License Law
does not appy to an owner of property who builds or bnproves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B.,& P.C. for this reason
Date _/- —/-owner
WORKERS' COMPENSATION DECLARATION
1 Hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
Policy No Company
❑ Copy is filed with the city. ❑ Certified copy is hereby fumished.
r
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(Ibis section need not be completed if the pemtit Is for one hundred da9m ($100) valuation
or less.)
I certify that in the performance of thg work for which this pernit.is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California / T
Date Owner ✓
NOTICE TO APPLICANT: ff, after making this Certificate of Exemption you should become
subject to the Wbrkeis' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Chd Code.)
Lenders Name
Lenders Address
This is abuilding permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 100 days.
I certify that I have read this application and state that the above information is correct
I agree to comply with all city and county ordinances and state laves relating to building
construction, and hereby authorize representatives .of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Tip
No. 05762
BUILDING: TYPE CONST. OCC: GRP.;
A.P. Number 617-383--019
Legal Descripti
Description
Sq. Ft.
Size
Patio
No.
Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
16.25
Const.
25.00
Mech.
Electrical
Plumbing
S.M.I.
.07
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS / r
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date 5/17/89Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL, AREA
SLAB GRADE
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REINF.
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
DRAINAGE PIPING
CAR P. SO. FT. ®
GROUT
DRINKING FOUNTAIN.
WALL SO. FT.
FINAL INSP.
BOND BEAM
URINAL
SOFT ®
GRADING
cu. yd.
$ plus x$
=$
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ®c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Va c
SEWAGE DISPOSAL
SO.FT.GAR ® 3Yac
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE tL.CK.FEE TONST.
FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL, AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION /
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
' GARDEN WALL FINAL
)